FW-001

Request to Waive Court Fees

CONFIDENTIAL
Clerk stamps date here when form is filed.

SAMPLE ONLY

If you are getting public benefits, are a low-income person, or do not have
enough income to pay for households basic needs and your court fees, you may
READ this carefully!
use this form to ask the court to waive all or part of your court fees. The court
may order you to answer questions about your finances. If the court waives the
fees, you may still have to pay later if:
You cannot give the court proof of your eligibility,
Fill in court name and street address:
Your financial situation improves during this case, or
Superior Court of California, County of
You settle your civil case for $10,000 or more. The trial court that waives
your fees will have a lien on any such settlement in the amount of the
waived fees and costs. The court may also charge you any collection costs.
Write in the court
Your
Information
(person
asking
the
court
to
waive
the
fees):
1
address here
Name:
Street or mailing address:
Fill in case number and name:
City:
State:
Zip:
Case Number:
Phone number:
Write your Case Number here
Your
Job,
if
you
have
one
(job
title):
2
Case Name:
Name of employer:
Complete
items
#1,
#2
&
#4.
Write your Case Name here
Employers address:

Do not fill out

this form

#3(name,
if you
a lawyer.
Your Lawyer, Fill
if youout
have one
firm have
or affiliation,
address, phone number, and State Bar number):

a. The lawyer has agreed to advance all or a portion of your fees or costs (check one): Yes
No
b. (If yes, your lawyer must sign here) Lawyers signature:
If your lawyer is not providing legal-aid type services based on your low income, you may have to go to a
hearing to explain why you are asking the court to waive the fees.
What courts fees or costs are you asking to be waived?
Superior Court (See Information Sheet on Waiver of Superior Court Fees and Costs (form FW-001-INFO).)
For question 5, check 'a', 'b', OR 'c':
Supreme Court, Court of Appeal, or Appellate Division of Superior Court (See Information Sheet on Waiver
If you
check # 5a, just make sure you check any box that
of Appellate Court Fees (form
APP-015/FW-015-INFO).)
applies
to your
you court
in 5a.fees?
Why are you asking the court
to waive
a.
I receive (check all that apply):
Medi-Cal
Stamps
SSI 9 on
SSP theCounty
If you check # 5b, Food
fill out
# 7,8 and
back.Relief/General
Then, you
IHSS (In-Home Supportive Services)
CalWORKS or Tribal TANF (Tribal Temporary
Assistance
are done!
Assistance for Needy Families)
CAPI (Cash Assistance Program for Aged, Blind and Disabled)
If you
check
fill out
ontheback
side
the form.
b.
My gross monthly household
income
(before#5c,
deductions
for everything
taxes) is less than
amount
listedofbelow.
(If
you check 5b, you must fill out 7, 8, and 9 on page 2 of this form.)
Family Size
1
2

Family Income
$1,215.63
$1,638.55

Family Size
3
4

Family Income
$2,061.46
$2,484.38

Family Size
5
6

Family Income
$2,907.30
$3,330.21

If more than 6 people

at home, add $422.92
for each extra person.

I do not have enough income to pay for my households basic needs and the court fees. I ask the court to
waive all court fees
waive some of the court fees
let me make payments over time
(check one):
(If
you
check
5c,
you must fill out page 2.)
(Explain):
Check #6 if you asked for a fee waiver in this case in the last 6
Check here if you asked the court to waive your court fees for this case in the last six months.
6
months.
Attachavailable,
that request
you have
it and
the here:)
second box.
(If your previous request
is reasonably
pleaseifattach
it to this
formcheck
and check
I declare under penalty of perjury under the laws of the State of California that the information I have provided
on this form and all attachments is true and correct.
Date: Write Today's Date here
c.

Sign Here

Print Your Name here

Print your name here

Judicial Council of California, www.courts.ca.gov
Revised February 20, 2014, Mandatory Form
Government Code, 68633 Cal. Rules of Court,
rules 3.51, 8.26, and 8.818

Sign here

Request to Waive Court Fees

FW-001, Page 1 of 2

Your name:

Print Your Name here

Case Number:

Write your Case Number here

If you checked 5a on page 1, do not fill out below. If you checked 5b, fill out questions 7, 8, and 9 only. If you
checked 5c, you must fill out this entire page. If you need more space, attach form MC-025 or attach a sheet
of paper and write Financial Information and your name and case number at the top.
7

Check here if your income changes a lot from month to month.

Fill out below based on your average income for the past 12
months.

8 Your Monthly Income

10 Your Money and Property

a. Cash

$
a. Gross monthly income (before deductions):
List each payroll deduction and amount below:
(1)
(2)

b. All financial accounts (List bank name and amount):

(1)
$

$
$
$
$

(2)

(3)

(4)

Cars, boats, and other vehicles

If you checked # 5b, fill out #c. 7,8
and 9. You do Fair
not
have
Market How Much You
Make / Year
Value
Still Owe
to 8a
fill(1)-(4)
outabove):
#10 and
#11.
b. Total deductions (add
$
(1)
$
$
c. Total monthly take-home pay (8a minus 8b): $
(2)
$
$
If you checked #5c, fill out everything
on this side
of the
d. List the source and amount of any other income you get each
(3)
$
$
month, including: form.
spousal/child support, retirement, social
security, disability, unemployment, military basic allowance for
d. Real estate
Fair Market How Much You
quarters (BAQ), veterans
payments,
dividends,
interest,the
trust items in this page, make sure you
When
you
answer
Value
Still Owe
Address
income, annuities, net business or rental income,
(1)
$
$
reimbursement forfill
job-related
gambling orand
lottery that the information is true and
out expenses,
everything
(2)
$
$
winnings, etc.
(3)
$
$
(1)
complete.
$
(3)
(4)

(2)
(3)
(4)

$
$
$

e. Your total monthly income is (8c plus 8d):

9 Household Income

a. List all other persons living in your home and their income;
include only your spouse and all individuals who depend in
whole or in part on you for support, or on whom you depend in
whole or in part for support.
Gross Monthly
Age Relationship Income
Name
$
(1)
(2)

(3)

(4)

b. Total monthly income of persons above:

Total monthly income and

household income (8e plus 9b):

e. Other personal property (jewelry, furniture, furs,

stocks, bonds, etc.):
Fair Market How Much You
Describe
Value
Still Owe
(1)
$
$
(2)

(3)

Monthly Expenses
11 Your
(Do not include payroll deductions you already listed in 8b.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Rent or house payment & maintenance

Food and household supplies
Utilities and telephone
Clothing
Laundry and cleaning
Medical and dental expenses
Insurance (life, health, accident, etc.)
School, child care
Child, spousal support (another marriage)
Transportation, gas, auto repair and insurance
Installment payments (list each below):
IfPaid
youto:want to add any more

$
$
$
$
$
$
$
$
$
$

READ this notice carefully!

information, attach form MC-025 or$ a

$
piece of paper, with your name, case
$
(3)
number and write Financial
l. Wages/earnings
courtDon't
order forget
$ to
Informationwithheld
at thebytop.
m. Any
$
other the
monthly
each below).
check
boxexpenses
in here(listtelling
the court
Paid to:
you
have attached another page. How Much?
(1)

To list any other facts you want the court to know, such
as unusual medical expenses, family emergencies, etc.,
attach form MC-025. Or attach a sheet of paper, and
write Financial Information and your name and case
number at the top. Check here if you attach another page.
Important! If your financial situation or ability to pay
court fees improves, you must notify the court within
five days on form FW-010.

(2)

(1)

(2)

(3)

Total monthly expenses (add 11a 11m above): $

Rev. February 20, 2014

Request to Waive Court Fees

FW-001, Page 2 of 2